The mental health challenges faced by doctors during the COVID-19 crisis

During acute health crises, healthcare services are placed under excess pressure, making working life even more stressful than normal.^{Reference Tam CW, Pang, Lam and Chiu19} In a pandemic, the number of patients requiring treatment increases significantly, placing strain on healthcare resources and on personnel alike. Additionally, doctors perceive a greater risk to self owing to their exposure to the patients who are most poorly – adding further stress.^{Reference Shiao, Koh, Lo, Lim and Guo20,Reference Chen, Lee, Barr, Lin, Goh and Lee21} Compounding this stress is the shortage of personal protective equipment (PPE) that can arise during a pandemic.^{Reference Devnani22} The perceived risk of infection is warranted: a meta-analysis of the occupational risk from the 2009 swine flu pandemic (influenza A (H1N1)) reports that the odds of healthcare personnel contracting the virus were twice those of comparison groups.^{Reference Lietz, Westermann, Nienhaus and Schablon23} This heightened risk for doctors and nurses might be due to their greater exposure to the respiratory secretions of patients.^{Reference Bhadelia, Sonti, McCarthy, Vorenkamp, Jia and Saiman24}

A further stressor is the increased risk of infection for the families of healthcare professionals on the front line.^{Reference Wong, Yau, Chan, Kwong, Ho and Lau25} Data from the 2009 swine flu pandemic shows that 20% of doctors and nurses with symptoms reported symptoms in at least one of their family members.^{Reference Choi, Chung, Jeon and Lee26} One way for front-line doctors to mitigate infection risk to their families is through social distancing. However, although the protective benefits of social contact and support at times of stress are well demonstrated,^{Reference Ma, Qiao, Qu, Wang, Huang and Cheng27} social distancing deprives the individual of a crucial buffer against mental health difficulties precisely when they are at greater risk of stress.^{Reference Huremović and Huremović28}

Research from previous epidemics/pandemics (such as the SARS outbreak from 2003, the MERS epidemic from 2012 or Ebola outbreaks in West Africa) shows that healthcare professionals can experience a broad range of psychological morbidities, including trauma,^{Reference Styra, Hawryluck, Robinson, Kasapinovic, Fones and Gold29,Reference Sim, Chong, Chan and Soon30} which might endure for many months after the outbreak.^{Reference Maunder, Lancee, Balderson, Bennett, Borgundvaag and Evans31,Reference Su, Lien, Yang, Su, Wang and Tsai32} The relationship between traumatic life events and suicide is well documented^{Reference McFeeters, Boyda and Siobhan33} and trauma from disaster events can increase suicidal ideation in emergency workers.^{Reference Stanley, Hom and Joiner34} Fears over risk to health and social isolation contribute to psychological distress,^{Reference Maunder, Lancee, Rourke, Hunter, Goldbloom and Balderson35} as do perceptions of ‘infection stigma’ from the community.^{Reference Bai, Lin, Lin, Chen, Chue and Chou36} However, the negative effects on mental health can be found in doctors irrespective of whether or not they worked directly with infected patients.^{Reference Um, Kim, Lee and Lee37} Although the strains of front-line healthcare during an infectious outbreak can lead to sickness absence and higher staff turn-over,^{Reference Shiao, Koh, Lo, Lim and Guo20,Reference Goulia, Mantas, Dimitroula, Mantis and Hyphantis38} most evidence suggests that doctors and nurses feel a strong professional obligation to continue working in spite of the danger.^{Reference Wong, Wong, Lee, Cheung and Griffiths39,Reference Khalid, Khalid, Qabajah, Barnard and Qushmaq40} However, given the pressures of needing to maintain high-quality healthcare provision during a pandemic, combined with doctors’ reluctance to seek help or disclose their difficulties, it is possible that this kind of professional commitment might relate strongly to presenteeism. Indeed, a recent review reported that physicians were at the highest risk of ‘infectious illness presenteeism’ when compared with a range of other occupational groups.^{Reference Webster, Liu, Karimullina, Hall, Amlôt and Rubin41}

Having to balance their own safety with the needs of patients, family and employers and in the face of limited resources can lead to distressing ethical dilemmas for doctors and, potentially, to moral injury. Moral injury can arise when one feels compelled to make decisions that conflict with one's ethical or moral values.^{Reference Litz, Stein, Delaney, Lebowitz, Nash and Silva42} The effect of moral injury on subsequent mental health can depend on the quality of support provided to employees during and after such events.^{Reference Greenberg, Docherty, Gnanapragasam and Wessely43}

Managing doctors’ stress at the organisational level during the outbreak

There is evidence that employer support for healthcare professionals during pandemics and disaster management can be very protective. Such support should include safeguards such as care for those doctors and nurses who become ill, in addition to medical and financial support for their families and protection from malpractice threat. Healthcare professionals’ motivation and morale are significantly improved when they perceive that their efforts are recognised and reciprocated by employers and authorities in these ways.^{Reference Damery, Draper, Wilson, Greenfield, Ives and Parry44,Reference Imai, Matsuishi, Ito, Mouri, Kitamura and Akimoto45} An important part of this support is the perceived efficacy of the training and personal protective equipment that healthcare professionals receive as well as the general quality of organisational leadership and communication.^{Reference Devnani22,Reference Aiello, Young-Eun Khayeri, Raja, Peladeau, Romano and Leszcz46,Reference Cates, Gomes, Krasilovsky, Hewlitt and Murthy47} These factors are important not just for motivation – they are also associated with better psychological outcomes in healthcare professionals on the front line during epidemics.

There are also many ways to tackle mental health stigma in the workplace. The foundation for this is creating a culture that encourages open communication and seeks to reduce the stigmatisation of psychological vulnerability.^{Reference Halpern, Gurevich, Schwartz and Brazeau48} This may include devising activities that challenge unhelpful attitudes and that instead promote desired values, as well as expanding knowledge and encouraging positive behavioural change.^{Reference Hanisch, Twomey, Szeto, Birner, Nowak and Sabariego49} The anti-stigma project Time to Change,^{Reference Henderson and Thornicroft50} provides a suite of simple interventions for implementation in the workplace.⁵¹ Elsewhere there is good evidence for peer support training in health crises or disaster management. One example is the Trauma Risk Management programme (TRiM), where non-clinical personnel are trained to assess peers following traumatic events and provide short-term support or access to professional care if required. Mental Health First Aid (MHFA) operates on a similar model and both it and TRiM can be effective in reducing mental health stigma in the workplace.^{Reference Imai, Matsuishi, Ito, Mouri, Kitamura and Akimoto45,Reference Cates, Gomes, Krasilovsky, Hewlitt and Murthy47}

Stress management at the individual level

There is evidence that psychological interventions for work stress can be effective in healthcare professionals.^{Reference Ruotsalainen, Verbeek, Mariné and Serra52} Recent reviews attest to the effectiveness of mindfulness-based interventions for work stress and suicide ideation;^{Reference Burton, Burgess, Dean, Koutsopoulou and Hugh-Jones53–Reference Williams, Duggan, Crane and Fennell57} mindfulness-based interventions also have a sound theoretical basis.^{Reference Hayes58,Reference Kabat-Zinn59} Mindfulness skills are particularly suited to high-stress work settings, in that they can be practised privately or in groups, in almost any environment and can be conducted as briefly as time permits. Negative automatic cognitions are a key trigger in stress reactions.^{Reference Feldman, Greeson and Senville60} Mindfulness interventions encourage us to ‘notice’ our thoughts and to view them as objective events that happen to us. This enables us to objectify our own negative thoughts, gaining a new perspective on how those thoughts influence our emotions and behaviour and enabling better management of the distress that would normally accompany them. The effectiveness of online mindfulness courses also has a good evidence base.^{Reference Spijkerman, Pots and Bohlmeijer61}